Complex Care

1. A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse
making rounds at 1545 finds that the client is complaining of a pounding headache and is
dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous
(IV) bag has 400 mL remaining. The nurse should take which action first?
1. Slow the IV infusion.
2. Sit the client up in bed.
3. Remove the IV catheter.
4. Call the primary health care provider (PHCP).

2. Packed red blood cells have been prescribed for a female client with anemia who has a
hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes
the client’s temperature before hanging the blood transfusion and records 100.6° F (38.1° C)
orally. Which action should the nurse take?
1. Begin the transfusion as prescribed.
2. Administer an antihistamine and begin the transfusion.
3. Administer 2 tablets of acetaminophen and begin the transfusion.
4. Delay hanging the blood and notify the primary health care provider (PHCP).

3. The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In
developing the plan of care, which priority problem should the nurse assign to this client?
1. Deficient fluid volume related to acute blood loss
2. Risk for aspiration related to acute bleeding in the GI tract
3. Risk for infection related to acute disease process and medications
4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and increased
metabolism

4. The nurse is assessing the functioning of a chest tube drainage system in a client with a chest
injury who has just returned from the recovery room following a thoracotomy with wedge
resection. Which are the expected assessment findings? Select all that apply.
1. Excessive bubbling in the water seal chamber
2. Vigorous bubbling in the suction control chamber
3. Drainage system maintained below the client’s chest
4. 50 mL of drainage in the drainage collection chamber
5. Occlusive dressing in place over the chest tube insertion site
6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

5. A client is brought to the emergency department with partial-thickness burns to his face, neck,
arms, and chest after trying to put out a car fire. The nurse should implement which nursing
actions for this client? Select all that apply.
1. Restrict fluids.
2. Assess for airway patency.
3. Administer oxygen as prescribed.
4. Place a cooling blanket on the client.
5. Elevate extremities if no fractures are present.
6. Prepare to give oral pain medication as prescribed.

6. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial
blood glucose level is 950 mg/dL (52.9 mmol/L). A continuous intravenous (IV) infusion of
short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose
level is now decreased to 240 mg/dL (13.37 mmol/L). The nurse would next prepare to
administer which medication?
1. An ampule of 50% dextrose
2. NPH insulin subcutaneously
3. IV fluids containing dextrose
4. Phenytoin for the prevention of seizures

7. The nurse is assessing a client with multiple trauma who is at risk for developing acute
respiratory distress syndrome. The nurse should assess for which earliest sign of acute
respiratory distress syndrome?
1. Bilateral wheezing
2. Inspiratory crackles
3. Intercostal retractions
4. Increased respiratory rate

8. A client is admitted to the emergency department with chest pain that is consistent with
myocardial infarction based on elevated troponin levels. Heart sounds are normal. The nurse
should alert the primary health care provider because the vital sign changes and client assessment
are most consistent with which complication? Refer to chart.
1. Cardiogenic shock
2. Cardiac tamponade
3. Pulmonary embolism
4. Dissecting thoracic aortic aneurysm

9. The nurse is caring for a client with chronic kidney disease on continuous replacement renal
therapy (CRRT) without the use of a hemodialysis machine. The nurse determines that which
parameter is most important in ensuring success of this treatment?
1. Mean arterial pressure (MAP)
2. Systolic blood pressure (SBP)
3. Diastolic blood pressure (DBP)
4. Central venous pressure (CVP)

10. The nurse is monitoring a client with a head injury for signs of increased intracranial
pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

11. A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to
institute which actions? Select all that apply.
1. Administer oxygen.
2. Quickly assess the client’s respiratory status.
3. Document the event, interventions, and client’s response.
4. Keep the client supine regardless of the blood pressure readings.
5. Leave the client briefly to contact a primary health care provider (PHCP).
6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

12. A client in shock develops a central venous pressure (CVP) of 2 mm Hg and mean arterial
pressure (MAP) of 60 mm Hg. Which prescribed intervention should the nurse implement first?
1. Increase the rate of O2 flow
2. Obtain arterial blood gas results
3. Insert an indwelling urinary catheter
4. Increase the rate of intravenous (IV) fluids

13. A client at risk for shock secondary to pneumonia develops restlessness and is agitated and
confused. Urinary output has decreased and the blood pressure is 92/68 mm Hg. The nurse
minimally suspects which stage of shock based on this data?
1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4

14. The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the
client may be entering a state of shock. The nurse knows that which intervention is the priority
for this client?
1. Administration of digoxin
2. Administration of whole blood
3. Administration of intravenous fluids
4. Administration of packed red blood cells

15. Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply.
1. Urine output 50 mL/hr
2. Hypoactive bowel sounds
3. Temperature of 102° F (38.9° C)
4. Heart rate of 96 beats per minute
5. Mean arterial pressure 65 mm Hg
6. Systolic blood pressure 110 mm Hg

1. Answer: 1 Rationale: The client’s symptoms are compatible with circulatory overload. This
may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action
of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may
elevate the head of the bed to aid the client’s breathing, if necessary. The nurse also notifies the
PHCP. The IV catheter is not removed; it may be needed for the administration of medications to
resolve the complication.
2. Answer: 4 Rationale: If the client has a temperature higher than 100° F (37.8° C), the unit of
blood should not be hung until the primary PHCP is notified and has the opportunity to give
further prescriptions. The PHCP likely will prescribe that the blood be administered regardless of
the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until
the temperature has decreased before administration, but the decision is not within the nurse’s
scope of practice to make. The nurse needs a PHCP’s prescription to administer medications to
the client.
3. Answer: 1 Rationale: The priority problem for the client with acute gastrointestinal bleeding
among these options is deficient fluid volume related to acute blood less. This state can result in
decreased cardiac output and hypovolemic shock. Although nutrition is a problem, fluid volume
deficit is more of a priority. The client is at risk for aspiration and infection, but these are not
actual problems at this point in time.
4. Answer: 3, 4, 5, 6 Rationale: The bubbling of water in the water seal chamber indicates air
drainage from the client and usually is seen when intrathoracic pressure is higher than
atmospheric pressure; it may occur during exhalation, coughing, or sneezing. Excessive bubbling
in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water
in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of
fluctuation may indicate that the chest tube is obstructed or that the lung has re-expanded and
that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted
in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning
to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hr is
considered excessive and requires notification of the surgeon. The chest tube insertion site is
covered with an occlusive (airtight) dressing to prevent air from entering the pleural space.
Positioning the drainage system below the client’s chest allows gravity to drain the pleural space.
5. Answer: 2, 3, 5 Rationale: The primary goal for a burn injury is to maintain a patent airway,
administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ
functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent
airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital
tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities
are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially
in the burn-injured upper extremities. The client is kept warm, because the loss of skin integrity
causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered
gastrointestinal function that occurs as a result of a burn injury.
6. Answer: 3 Rationale: Emergency management of DKA focuses on correcting fluid and
electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too
quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During
management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (13.9 to 16.7
mmol/L), the IV infusion rate is reduced and a dextrose solution is added to maintain a blood
glucose level of about 250 mg/dL (13.9 mmol/L), or until the client recovers from ketosis. Fifty
percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin
is not a usual treatment measure for DKA.
7. Answer: 4 Rationale: The earliest detectable sign of acute respiratory distress syndrome is an
increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body.
This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and
cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse
crackles. Test-
8. Answer: 1 Rationale: Cardiogenic shock occurs with severe damage (more than 40%) to the
left ventricle. Classic signs include hypotension; a rapid pulse that becomes weaker; decreased
urine output; and cool, clammy skin. Respiratory rate increases as the body develops metabolic
acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and
prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea
accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back
pain.
9. Answer: 1 Rationale: Continuous renal replacement therapy (CRRT) provides continuous
ultrafiltration of extracellular fluid and clearance of urinary toxins over a period of 8 to 24 hours;
it is used primarily for clients with acute kidney injury (AKI) or critically ill clients with chronic
kidney disease (CKD) who cannot tolerate hemodialysis. Water, electrolytes, and other solutes
are removed as the client’s blood passes through a hemofilter. If CRRT does not require a
hemodialysis machine, the client’s MAP needs to be maintained above 60 mm Hg, and arterial
and venous access sites are necessary. The SBP, DBP, and CVP may be monitored but each of
these measures a component of the cardiovascular status rather than the complete cardiac cycle.
10. Answer: 2 Rationale: A change in vital signs may be a late sign of increased intracranial
pressure. Trends include increasing temperature and blood pressure and decreasing pulse and
respirations. Respiratory irregularities also may occur.
11. Answer: 1, 2, 3 Rationale: An anaphylactic reaction requires immediate action, starting with
quickly assessing the client’s respiratory status. Although the PHCP and the Rapid Response
Team must be notified immediately, the nurse must stay with the client. Oxygen is administered
and an IV of normal saline is started and infused per PHCP 2568 prescription. Documentation of
the event, actions taken, and client outcomes needs to be done. The head of the bed should be
elevated if the client’s blood pressure is normal.
12. Answer: 4 Rationale: The MAP and CVP are both low for this client, indicating a shock
state. Shock is the result of inadequate tissue perfusion. Fluid volume should be immediately
restored first to provide adequate perfusion for the client in a shock state. Although increasing
the rate of O2 flow may be a necessary intervention, perfusion is the first priority. Obtaining
arterial blood gas results and inserting an indwelling urinary catheter may be necessary
interventions to monitor the client’s response to prescribed therapy, but these are not the priority.
13. Answer: 2 Rationale: Shock is categorized by 4 stages. Stage 1 is characterized by
restlessness, increased heart rate, cool and pale skin, and agitation. Stage 2 is characterized by a
cardiac output that is less than 4 to 6 liters per minute, systolic blood pressure less than 100 mm
Hg, decreased urinary output, confusion, and cerebral perfusion pressure that is less than 70 mm
Hg. Stage 3 is characterized by edema, excessively low blood pressure, dysrhythmias, and weak
and thready pulses. Stage 4 is characterized as unresponsiveness to vasopressors, profound
hypotension, slowed heart rate, and multiple organ failure. Most often, the client will not survive.
14. Answer: 1 Rationale: The client in this question is likely experiencing cardiogenic shock
secondary to heart failure exacerbation. It is important to note that if the shock state is
cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema;
therefore, restoration of cardiac function is the priority for this type of shock. Cardiotonic
medications such as digoxin, dopamine, or norepinephrine may be administered to increase
cardiac contractility and induce vasoconstriction. Whole blood, intravenous fluids, and packed
red blood cells are volume-expanding fluids and may further complicate the client’s clinical
status; therefore, they should be avoided.
15. Answer: 3, 4, 5 Rationale: Sepsis diagnostic criteria with regard to signs and symptoms
include the following: Fever (temperature higher than 100.9° F [38.3° C]) or hypothermia (core
temperature lower than 97° F [36° C]), tachycardia (heart rate above 90 beats per minute),
tachypnea (respiratory rate above 22 breaths per minute), systolic blood pressure (SBP) less than
or equal to 100 mm Hg or arterial hypotension (SBP below 90 mm Hg), MAP less than 70 mm
Hg, or a decrease in SBP of more than 40 mm Hg, altered mental status, edema or positive fluid
balance, oliguria, ileus (absent bowel sounds), and decreased capillary refill or mottling of skin.